CHDO Recertification

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Annabella Heath
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Organization Information Organization Legal Name: CHDO Recertification Tax ID Number: DUNS Number: Mailing Address (include physical address if different from mailing address): Contact Name/Title:

1 Organization Information Organization Legal Name: CHDO Recertification Tax ID Number: DUNS Number: Mailing Address (include physical address if different from mailing address): Contact Name/Title: Organization President/CEO/Executive Director (name and title): Phone: Fax: Address: Board President Name: Phone: Fax: Address: Phone: Fax: Original CHDO Certification Date: Address: Activities Please describe the CHDO-eligible activities your organization plans to undertake in connection with this certification/ recertification. Service Area Service Area Service Area County County General CHDO New? General CHDO New? Page 1 of 6

2 CHDO Certification/Recertification Status WVHDF Use Only Date of most recent WVHDF CHDO Certification/Recertification: I. Financial Status WVHDF Use Only Attach a copy of the organization s most-current annual operating budget as Attachment 1. Date of audit submitted with most recent CHDO certification/recertification: Is a more recent audit (less than 12 months old) available? YES (attach as Attachment 2) II. Legal Status C. The nonprofit organization is organized under State or local laws. Have any of the following changed since the most recent CHDO Charter--OR--Articles of Incorporation YES (attach as Attachment 3, Bylaws YES (attach as Attachment 4, Attach a copy of the Resolution Authorizing Recertification as CHDO for this CHDO Activity (Attachment 5) Resolution for CHDO projects should include project name, amount of funding, who is authorized to execute agreements and any other pertinent information. Resolution for Operating Expense Grant should include amount of funding, who is authorized to execute agreements and any other pertinent information. Attach a copy of the Certificate of Existence (current as of 7 days of the date of this submission) (Attachment 6) Has the organization retained its 501(c) status with the IRS since its most-recent CHDO YES If No, attach a copy of IRS letter indicating change in status as Attachment 7. Has the organization revised its purpose or mission statement since its most-recent CHDO YES Identify the changed Section(s): Page 2 of 6

3 III. Capacity C. Organization has demonstrated capacity for carrying out activities assisted with HOME funds. As Attachment 8, please complete and attach: Staff Member Information form (WVHDF Form CHDO-100); -AND- Résumés that describe the experience of key staff members who have successfully completed projects similar to those to be assisted with HOME funds. Does the organization have a contract with a consultant to train appropriate staff members? YES Attach a copy of the contract as Attachment 9. Has the organization amended its Procurement Policy since its most-recent CHDO YES Attach the amended Procurement Policy as Attachment 10, D. E. Do the organization s financial accountability standards conform to 24 CFR 84.21, Standards for Financial Management Systems? YES Complete the Certification of Financial Management Systems form (WVHDF Form CHDO-103), page 6 of this document NO Has the organization amended its Conflict of Interest Policy since its most-recent CHDO YES Attach a copy of the Conflict of Interest Policy as Attachment 11, IV. Organizational Structure Has the organization s formal process by which low-income beneficiaries advise the organization in all of its decisions regarding the design, siting, development, and management of its HOME-assisted affordable housing activities changed since its most-recent CHDO YES Attach the updated process as Attachment 12. V. Board Certification The Board and its low-income representatives must certify that they meet the low-income CHDO requirements. As Attachment 13, for each board member, please complete and attach: Certification of Low-Income Representation form (WVHDF Form CHDO-101) As Attachment 14, please complete and attach: Board Member Requirements form (WVHDF Form CHDO-102) Do board members have professional skills directly relevant to housing development (e.g., real estate, legal, architecture, finance, management)? YES Attach documentation of experience for board members as Attachment 15. Page 3 of 6

4 WVHDF USE ONLY Approved Disapproved HOME PROGRAM Manager: Date: Page 4 of 6

5 Statement of Certification CHDO-B I hereby certify that all statements I have provided in this recertification and in the attachments herein are true and comply with West Virginia law; that I am authorized to sign this recertification and to make these statements on behalf of the applicant organization; and that the organization understands that misrepresentation of any facts which lead to the improper allocation and expenditure of public funds may result in legal action against the organization for retrieval of any such funds and appropriate penalties. Name (Typed) Date Title (Executive Director, etc.) Signature STATE OF WEST VIRGINIA, COUNTY OF, To-Wit: The foregoing instrument was acknowledged before me this day of, 2, by (name of officer), (title of officer) of (organization name), a notfor-profit West Virginia corporation, on behalf of said corporation. My commission expires NOTARY PUBLIC I hereby certify that the submission of this recertification has been approved by a two-thirds vote of the Board of Directors. Name (Typed) Date Board President Signature STATE OF WEST VIRGINIA, COUNTY OF, To-Wit: The foregoing instrument was acknowledged before me this day of, 2, by (name of officer), (title of officer) of (organization name), a notfor-profit West Virginia corporation, on behalf of said corporation. My commission expires NOTARY PUBLIC Page 5 of 6

6 2/2014 CHDO-103 (7/15/09) CERTIFICATION OF FINANCIAL MANAGEMENT SYSTEMS I, (insert name and title of officer) of (insert legal name of organization) do hereby certify that said organization maintains and has in place a functioning financial management system that conforms to the requirements of 24 CFR 84.21, as stated below: 1. Accurate, current, and complete disclosure of the financial results of each federally-sponsored project or program in accordance with the reporting requirements set forth in Section If a recipient maintains its records on other than an accrual basis, the recipient shall not be required to establish an accrual accounting system. These recipients may develop such accrual data for their reports on the basis of an analysis of the documentation on hand. 2. Records that identify adequately the source and application of funds for federally-sponsored activities. These records shall contain information pertaining to federal awards, authorizations, obligations, unobligated balances, assets, outlays, income, and interest. 3. Effective control over and accountability for all funds, property, and other assets. Recipients shall adequately safeguard all such assets and assure they are used solely for authorized purposes. 4. Comparison of outlays with budget amounts for each award. Whenever appropriate, financial information should be related to performance and unit cost data. 5. Written procedures for determining the reasonableness, allocability, and allowability of costs in accordance with the provisions of the applicable federal cost principles and the terms and conditions of the award. 6. Accounting records including cost accounting records that are supported by source documentation. Dated this day of, 2. (insert legal name of organization) By: Its: STATE OF WEST VIRGINIA, COUNTY OF, To-Wit: The foregoing instrument was acknowledged before me this day of, 2, by (name and title of officer) of, a West Virginia nonprofit corporation, on behalf of said nonprofit corporation. My commission expires. NOTARY PUBLIC Page 6 of 6

APPLICATION FOR PUBLIC SERVICE PROGRAMS

PY 2018 Application Form for the Community Development Block Grant Program (Reproduce this form as necessary or copy this form onto your Official Letterhead) Date: APPLICATION FOR PUBLIC SERVICE PROGRAMS